Motor Accident Claim

No 2 The Colosseum Building
Century City  Boulevard

 Century City

PO Box 90 Century City 7446
Tel: (27) (21) 529 7800 
Fax: 0865 202 355
E-mail: insure@aib.co.za
 Insured
Name
Surname
Address
Telephone
Fax
E-mail
Occupation
Identification Number
Policy Number
 Vehicle
Make
Model
Year
Registration
Kilometers Completed
Purchase Date
Purchase Price
Name of Registered Owner
 Damage
Damage to own vehicle
Estimate for repairs (Please fax a quatation to us)
Repairer's Name, Phone number and address
Where can your damaged vehicle be inspected?
 Driver
Name
Surname
Address
Identification Number
Driving License
Number
Date
Place
Code
State fully the purpose for which the vehicle was used
Was he/she driving with your permission? Yes    No
Is he/she the owner of another vehicle? Yes    No
If yes, give name of insurer and policy number
Details of any convictions for motoring offenses
Has license ever been endorsed? Yes    No
Has he/she any physical defects? Yes    No
Details of previous accidents
 Passengers (insured vehicle)
Passengers in ensured vehicle:
Name Address Injury
For what purpose were they carried?
Are they employees? Yes    No
 Other Party
Other vehicles:
Registration No Make Owner Address Of Owner Details of damage
Property other than vehicles:
Owner Address of owner Details of damage
Personal injuries (other than in insured vehicle):
Name Relationship to accident Details of injuries Hospital (if applicable)
 Witnesses
Name Address Phone Number
 Accident
Date and time
Place
Speed before accident
Speed at moment of impact
Weather conditions
Visibility
Road Surface
Width of road
Which vehicle lights were on?
Street Lighting
Was any warning given to you? e.g. hooting, indicator etc.
Name of police/traffic officer who recorded accident
Police station and reference number
Was driver tested for alcohol or drugs? Yes    No
Description of accident
 Notes
Please fax a sketch of the accident as well as copies drivers licence and identification document of the driver of the insured vehicle to us.
 Signature
Name
Signature
Please print the completed form and fax the signed document to 0865 202 355